HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 267 CHICKERING ROAD 7/26/2021 Commonwealth of Massachusetts R�CE�v -D
W City/Town of North Andover 20
System Pumping Record ? NPNpOv�R
Form 4 wNOFNo�PPtz�MEN�
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 267 Chickering Road
key to move your Address
cursor-do not North Andover MA 01845
use the return --— —
key.
City/Town State Zip Code
2. System Owner:
rab
Ninety Nine
Name
renen
Address(if different from location)
North Andover MA_ 01845
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date te - - - 2. Quantity Pumped. 3500 -
D Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap
❑ Other(describe).-
4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ® No
5. Observed condition of component pumped:
Normal water level. 36in bottom sludge. 36in top solids. Both baffles are intact. Main line Clear..
Cover(s) secured. Solids have overwhelmed this tank.-Did the best i could with a 4 inch hose.
6. System Pumped By:
Justin Beaudoin
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
WSG
3.9.21
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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